Question 1
The nurse assesses a patient with Chronic Renal Failure notes crackles in the lung bases, elevated blood pressure, and weight gain of 1 kg in one day.
Based on these finding, which of the following nursing diagnoses is the MOST appropriate for this patient?
- AOption A:
Increased cardiac output related to fluid overload
- BOption B:
Ineffective tissue perfusion related to interrupted arterial blood flow
- COption C:
Imbalance nutrition more than body requirements related to dietary excess
- DOption D:
Show answer and explanation
Correct answer: D
The patient's symptoms—crackles in the lung bases, elevated blood pressure, and rapid weight gain—are indicative of fluid overload, which is a common issue in chronic renal failure due to the kidneys' inability to excrete excess fluid.
Increased Cardiac Output Related to Fluid Overload : Increased cardiac output would not typically result from fluid overload; rather, fluid overload can lead to decreased cardiac output due to strain on the heart.
Ineffective Tissue Perfusion Related to Interrupted Arterial Blood Flow : This diagnosis does not directly correlate with the symptoms of fluid overload observed in this patient.
Imbalanced Nutrition More Than Body Requirements Related to Dietary Excess : This diagnosis is not relevant to the observed symptoms, which are more clearly related to fluid retention rather than dietary intake.
Excess Fluid Volume Related to the Kidney's Inability to Maintain Fluid Balance : This is the most appropriate nursing diagnosis as it directly addresses the kidney's failure to regulate fluid balance, leading to the observed clinical signs.
References :
National Kidney Foundation: Clinical Practice Guidelines for Chronic Kidney Disease
Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care